BACKGROUND:Hepatic venous pressure gradient (HVPG) increases significantly after endoscopic therapy in patients with bleeding oesophageal varices, which may precipitate further haemorrhage. Whether vasoactive drugs can suppress these changes remains unknown.AIM:To investigate the efficacy of somatostatin when compared with octreotide in preventing the post-endoscopic increase in HVPG during acute bleeding and whether the changes affect outcome.METHODS:Thirty-three cirrhotics with bleeding varices were randomized to receive somatostatin (n = 17) or octreotide (n = 16) under double-blind conditions, soon after their admission. HVPG measurements were performed before and immediately after endoscopic treatment.RESULTS:In the somatostatin group, postendotherapy HVPG values did not change significantly when compared with pre-treatment values (18.9 vs. 17.2, P = 0.092). Conversely, in the octreotide group, HVPG increased significantly after endoscopy (18.2 vs. 20.8, P = 0.003). The probability of 6-week survival without treatment failure was significantly higher in the somatostatin group (P = 0.024). Post-endoscopic HVPG value was independently associated with 6-week failure.CONCLUSIONS:Somatostatin, but not octreotide, effectively prevents the post-endoscopic increase in HVPG, which may be associated with low probability of treatment failure.

Management of patients with malignant obstructive jaundice is often challenging for all specialists involved in their care. In cases of unresectable tumors, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) can be used to palliate the symptoms of biliary obstruction. However, despite successful initial stent placement, tumoral ingrowth may occur, resulting in recurrence of jaundice. Deployment of a new endoprosthesis can be technically problematic, since both tumoral ingrowth and the previously placed stent make attempts for bile duct cannulation troublesome. We report a case of a difficult malignant biliary stricture successfully drained endoscopically, using established, as well as novel techniques.

Intracerebral hemorrhage is a serious and potentially fatal neurologic event that typically occurs in patients with hypertension. Other risk factors for this condition are anticoagulant drug use, bleeding disorders, and cerebral aneurysms.1 There has been no previous report, to our knowledge, of an intracerebral hemorrhage after an upper-GI endoscopy in the medical literature so far. We present the first case of an intracerebral hemorrhage complicating therapeutic upper-GI endoscopy, and we propose potential pathogenetic mechanisms.

Ulcerative colitis and Crohn's disease are complex disorders reflected by wide variation in clinical practice.Lifelong maintenance treatment is recommended for all patients with ulcerative colitis, especially those with left sided or extensive disease and those with distal disease, who relapse more than once a year. Oral mesalazine 2g/day should be considered as first-line therapy. Steroids are not effective at maintaining remission. Azathioprine 1,5-2,5 mg/kg/day or mercaptopurine 0,75-1,5 mg/kg/day should be reserved for patients who frequently relapse, despite adequate doses of aminosalicylates. Patients who have failed to respond to immunomodulators benefit from repeated maintenance therapy with infliximab, ideally on an every 8 week basis.The efficacy of drug therapy in the maintenance treatment of Crohn's disease depends on whether remission was achieved with medical or surgical therapy, on the risk of relapse and on the site of disease. Mesalazine seems to be ineffective at doses < 2 g/day. It is clearly ineffective for those who have needed steroids to induce remission. Azathioprine should be reserved as second line therapy. Steroid dependent patients and patients with steroid refractory disease should be considered for treatment with immunomodulators. Infliximab is effective at a dose of 5 mg/kg every 8 weeks in patients who have responded to the initial infusion. It is best used with immunomodulators. Moreover, it is the best evidenced-based therapy for the fistulating disease at the present time.Ulcerative colitis and Crohn's disease, collectively termed inflammatory bowel disease, are complex disorders reflected by wide variation in clinical practice.

02B. Cirrhosis' and complications (b) Clinical aspects'$95 serum ferritin ~>1000gg/L predicted the presence of cirrhosis with a sensitivity, specificity, positive and negative predictive values of 96%, 58%, 44% and 98%.Alcohol intake was not an independent predictor of advanced fibrosis/cirrhosis in our cohort.Conclusions: The published criteria have very low specificity in predicting advanced fibrosis/cirrhosis and do not reduce the need of liver biopsy in patients with genetic haemochromatosis.Using ferritin ~> 1000 gg/L on its own would halve the number of liver biopsies performed with minimal reduction in sensitivity.

BACKGROUND:The most frequent indication for capsule endoscopy is to diagnose the cause of obscure GI bleeding. The objective of the study was to determine the impact of capsule endoscopy on the outcome of patients with GI bleeding of obscure origin.METHODS:Ninety-six patients (53 men, 43 women; mean [standard deviation] age, 60.84 years [16.55 years]) were enrolled in the study. All patients have been subjected to gastroscopy, colonoscopy, small-bowel barium follow-through or enteroclysis, and push enteroscopy; no bleeding site had been identified. Capsule endoscopy was performed with the Given M2A video capsule system. By using strict criteria, studies were classified as having positive findings, findings of uncertain significance, and no findings. Outcome was defined as continued or complete resolution of bleeding.RESULTS:Positive findings, findings of uncertain significance, and no findings were identified in 41.7%, 20.8%, and 37.5% of our study population, respectively. The most common lesions seen were angiodysplasias of the small intestine. Therapeutic intervention was possible in 82.5% of patients with positive findings and in 35.0% of patients with findings of uncertain significance. Complete resolution of bleeding, after a median (interquartile range) follow-up period of 14 months (9-17 months), occurred significantly more often in patients with positive findings (68.4%) compared with patients with findings of uncertain significance and no findings (40.8%, p = 0.009).CONCLUSIONS:Capsule endoscopy increases the diagnostic yield in the workup of patients with obscure small-bowel bleeding. Strictly defined positive findings are associated with a favorable outcome.

M2A wireless capsule endoscopy (Given Imaging, Ltd., Yoqneam, Israel) is an innovative diagnostic method that makes it possible to visualize the entire small bowel during normal peristalsis [1]. This new method appears to be superior to small-bowel radiography (enteroclysis or barium follow-through, or both) for evaluating small-bowel diseases [2] [3]. However, its true diagnostic yield is still under evaluation. We describe here the case of a 76-year-old man with a 5-year history of celiac disease, who initially had complete clinical remission and histological improvement after switching to a gluten-free diet, but whose symptoms subsequently recurred despite strict adherence to dietary restrictions.

BACKGROUND: Cardiorespiratory complications may occur during gastrointestinal endoscopy, and elderly people seem to be more vulnerable to these complications during endoscopic procedures involving the manipulation of abdominal viscera. OBJECTIVES: To determine the incidence of cardiac arrhythmias, changes in oxygen saturation, heart rate and blood pressure during endoscopic retrograde cholangiopancreatography (ERCP) via Holter monitoring in elderly patients older than 70 years of age.METHODS: Holter monitoring and 12-lead electrocardiograms were performed in 30 elderly patients undergoing ERCP and in 30 control subjects undergoing routine chest, abdomen, bone and upper gastrointestinal small bowel follow-through studies. A computerized nontriggered template system was used to analyze the electrocardiograms qualitatively and quantitatively. Arrhythmias, cardiac axis, conduction defects, pauses, ST segment changes, ectopic beats, oxygen desaturation and changes in blood pressure and rate-pressure product were evaluated.RESULTS: Increased heart rate, ST segment changes resulting from myocardial ischemia, oxygen desaturation and transient atrial and ventricular ectopic beats were frequent during ERCP compared with the control group. In one patient, transient left bundle branch block developed and this was attributed to pre-existing hypertension with cardiomegaly. One patient developed ventricular tachycardia and one other sinus bradycardia, but this was attributed to sick sinus syndrome.CONCLUSIONS: Transient myocardial ischemia and various cardiac arrhythmias are frequent in elderly patients undergoing ERCP. Appropriate noninvasive monitoring seems to be justified during this procedure.

BACKGROUND/AIMS:Endoscopic ultrasonography presents a significant progress in imaging methods for the examination of the digestive system and is commonly used in cancer staging. The aim of this study was to quantify the potential of this modality for diagnosis and staging of colorectal cancer. METHODOLOGY:Eighty patients with histologically proven colorectal cancer were included in this study. All patients were preoperatively diagnosed by colonoscopy and biopsies, abdominal computed tomography and endoscopic ultrasonography. The latter was also used to evaluate the depth of tumor invasion and presence of lymph node or distant metastasis prior to surgery. RESULTS:Endoscopic ultrasonography presented 100% sensitivity in cancer detection versus 60% for computed tomography (P < 0.001). Endoscopic Ultrasonography sensitivity in T, N, M and TNM staging was 93.8%, 93.8%, 92.5% and 82.5% with corresponding specificities of 99.2%, 97.9%, 92.5% and 94.2%. Overall, Endoscopic Ultrasonography staging of the patients did not present statistically significant differences with histological staging (P > 0.05). CONCLUSIONS:Endoscopic ultrasonography is of satisfactory accuracy in diagnosis and preoperative staging of colorectal cancer.

A 72-year-old woman without significant medical history was admitted with abdominal pain, high fever, leukocytosis, bloody diarrhea and marked dilation of the transverse, descending and sigmoid colon. Toxic megacolon was diagnosed and responded well to medical treatment. Seven weeks after her admission, however, the patient developed a stenotic lesion in the sigmoid colon. The lesion was managed surgically. Histological examination of the resected colon revealed resolving ischemic colitis affecting only part of the thickness of the intestinal wall. The patient has been healthy since the surgery, i.e., for two years.